SUPPLEMENT ARTICLE
Open Reduction and Internal Fixation of the Posteromedial
Tibial Plateau via the Lobenhoffer Approach
Mark E. Hake, MD and James A. Goulet, MD
Summary: Posteromedial fractures of the tibial plateau are often
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encountered after high-energy injuries. They can be seen in isolation
or in combination with lateral column fractures. These fractures must
be recognized and stabilized independently of any lateral sided
fracture to ensure the stability of the final construct. First described
in 1997, the Lobenhoffer approach provides access to the poster-
omedial and posterior aspects of the proximal tibia, allowing for
reduction and stabilization of fractures in this location with a poster-
omedial plate. We present our technique for this approach for the
treatment of an isolated posteromedial tibial plateau fracture. The
procedure is performed in the prone position. An interval between
the gastrocnemius and pes anserine is developed and the fracture
apex visualized. The reduction maneuver involves extension and
valgus of the knee along with direct manipulation of the fracture
fragment. A small fragment antiglide plate is then placed to stabilize
the fracture. This relatively straightforward approach is of great use
when treating complex tibial plateau fractures involving the medial
and posterior columns.
Key Words: tibial plateau fracture, Lobenhoffer approach, poster-
omedial fragment, Moore type 1
Video available at: http://links.lww.com/BOT/A706.
(J Orthop Trauma 2016;30:S35–S36)
F ractures that involve the posteromedial tibial plateau are
seen with high-energy injuries and require special attention
when developing a preoperative plan. These medial-sided
fractures often require a separate medial approach and plating
strategy because an isolated lateral plate will not adequately
stabilize a displaced medial plateau. Here, we describe this
approach and tips for reduction and fixation in a case of an
isolated posteromedial tibial plateau fracture.
The Lobenhoffer approach was first described in the
German literature in 2003 and is used to access the poster-
omedial and posterior aspects of the tibial plateau. It allows for
visualization of the posteromedial tibia and, if needed, can be
developed laterally to allow access to the posterior and even
Accepted for publication March 8, 2016.
From the Department of Orthopaedic Surgery, University of Michigan Health
System, Ann Arbor, MI.
The authors report no conflict of interest.
Reprints: Mark E. Hake, MD, Department of Orthopaedic Surgery, Univer-
sity of Michigan Health System, 1500 E. Medical Center Dr, 2914
Taubman Center, Rm 2912, Ann Arbor, MI 48109-5328 (e-mail:
mhake@med.umich.edu).
Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.
DOI: 10.1097/BOT.0000000000000582
J Orthop Trauma  Volume 30, Number 8 Supplement, August 2016
Copyright Ó 2016 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
posterolateral tibia. There are numerous advantages to this
approach. The neurovascular bundle is not exposed and
therefore is protected within the posterior soft tissues. Wound
healing and coverage of implants is reliable because of the
large soft-tissue envelope over the posteromedial proximal
tibia. The visualization provided by the Lobenhoffer approach
allows for accurate reduction of the extraarticular portion of the
fracture followed by placement of a posterior antiglade plate.
The case presented is of a 39-year-old man who was
involved in a dirt bike accident. He was found to have
a posteromedial tibial plateau fracture (OTA 41-B3.2, Moore
type 1) and taken for closed reduction and knee-spanning
external fixation. Definitive fixation is delayed until healing
of the soft-tissue envelope. The patient can be placed in either
the prone or supine position. The prone position offers easier
access to the fracture site, manipulation of the limb for
reduction, and easier placement of hardware but requires
flipping the patient if an anterolateral approach is required.
The incision is made along the border of the medial
head of the gastrocnemius extending distally from the joint
line for a length of 6–8 cm. The popliteal fossa is not crossed
reducing the risk of contracture. The small saphenous vein is
seen between the 2 heads of the gastrocnemius and protected.
The fascia of the medial head of the gastrocnemius is incised
and the muscle is retracted laterally. The pes anserinus ten-
dons are seen in the proximal portion of the wound. This
structure can be retracted medially, or if required for adequate
visualization, released, and later repaired at the end of the
procedure. Blunt dissection between the medial gastrocne-
mius and the pes anserinus is taken down to the popliteus,
which is gently released from the tibia in a subperiosteal
fashion to reveal the fracture. A submeniscal arthrotomy is
rarely needed with the approach, as an anatomic reduction can
be obtained with only visualization of the distal fracture line.
Reduction of the fracture is performed with extension
and valgus force of the knee, axial traction, and an anteriorly
directed force on the fracture fragment. The reduction is
indirect and judged based on the apex of the fracture and on
intraoperative fluoroscopy. The fracture pattern and location
will determine the plating strategy. Most commonly, a “T”
plate placed in an antiglide fashion will stabilize the fracture
and prevent loss of reduction. A small fragment, nonlocking
plate is typically best for this purpose. The gastrocnemius
fascia and skin are then being closed in layers. Postoperative
toe-touch weight bearing is used for 8–12 weeks with range
of motion as tolerated. Patients typically tolerate this
approach and hardware because of the excellent soft-tissue
coverage.
www.jorthotrauma.com | S35
Hake and Goulet J Orthop Trauma  Volume 30, Number 8 Supplement, August 2016

Although numerous approaches have been described to
access the posterior and medial tibial plateau, the Lobenhoffer
approach offers a safe alternative to address posteromedial
fractures often seen in high-energy tibial plateau fractures. It
allows for direct visualization of the fracture fragment for
accurate reduction and plating. The posterior neurovascular
bundle is protected and the soft-tissue envelope allows for
reliable wound healing. Utilization of this approach will
maximize treatment of isolated posteromedial and bicondylar
fractures of the tibial plateau.

S36 | www.jorthotrauma.com Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.

Copyright Ó 2016 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.